Provider First Line Business Practice Location Address:
120 SOUTH APPLE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SHOSHONE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-934-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2016